Feline chronic gingivostomatitis with calicivirus infection

Abstract

Feline chronic gingivostomatitis (FCGS) is an oral inflammatory condition that frequently affects felines. Its etiology is not well defined, but several viral agents are thought to be involved. Several therapeutic protocols have been described, yet treatment response is often variable, and the therapeutic success is transient with an unpredictable duration. Therefore, the therapeutic strategy needs to be tailored for each patient. This work relates a case characterized by viral involvement in its etiopathogenesis providing an alternative to the most widely-used methods that so often frustrate both veterinary doctors and pet owners.

Full text

CASE REPORT
Braz. J. Vet. Res. Anim. Sci., São Paulo, v. 55, n. 3, p. 1-5, e141344, 2018
DOI: 10.11606/issn.1678-4456.bjvras.2018.141344
Feline chronic gingivostomatitis with calicivirus infection: case
report
Gengivostomatite crônica felina com infecção por calicivírus: relato de caso
Aline Silvestrini da SILVA1; Fernanda Campos HERTEL1; Mayara Pereira LOTÉRIO1; Jéssica Miranda COTA1;
Bruna Giannakopoulos RODRIGUES2; Marcus Rebouças SANTOS1; Emily Correna Carlo REIS3
1 Universidade Federal de Viçosa, Programa de Pós-Graduação em Medicina Veterinária, Viçosa – MG, Brazil
2 Universidade Federal de Viçosa, Programa de Residência em Medicina Veterinária, Viçosa – MG, Brazil
3 Universidade Federal de Viçosa, Departamento de Medicina Veterinária, Viçosa – MG, Brazil
Abstract
Feline chronic gingivostomatitis (FCGS) is an oral inflammatory condition that frequently affects felines. Its etiology is not well
defined, but several viral agents are thought to be involved. Several therapeutic protocols have been described, yet treatment
response is often variable, and the therapeutic success is transient with an unpredictable duration. Therefore, the therapeutic
strategy needs to be tailored for each patient. This work relates a case characterized by viral involvement in its etiopathogenesis
providing an alternative to the most widely-used methods that so often frustrate both veterinary doctors and pet owners.
Keywords: Feline chronic gingivostomatitis. Feline. Interferon. Calicivirus.
Resumo
A gengivostomatite crônica felina (FCGS) é uma condição inflamatória oral que frequentemente afeta felinos. A sua etiologia
não está bem definida, mas acredita-se que vários agentes virais possam estar envolvidos. Muitos protocolos terapêuticos têm
sido descritos, no entanto, a resposta ao tratamento é frequentemente variável e o sucesso terapêutico é transitório com uma
duração imprevisível. Portanto, a estratégia terapêutica precisa ser adaptada para cada paciente. O presente trabalho propõe a
caracterização do envolvimento viral na etiopatogenia da doença como uma alternativa aos métodos mais amplamente
utilizados, que muitas vezes frustram médicos veterinários e os donos de animais de estimação.
Palavras-chave: Gengivostomatite crônica felina. Felinos. Interferon. Calicivírus.
Feline chronic gingivostomatitis (FCGS) is a
chronic oral inflammatory condition that frequently
affects felines (LYON, 2005). Its etiology is not well
defined, but the immune system is thought to be
involved in its pathogenesis (VEIR et al., 2002;
LYON, 2005). Several therapeutic protocols are
described with medical and/or surgical approaches.
Clinical studies point to the involvement of several
viral agents in FCGS etiopathogenesis, including
feline calicivirus (FCV) (LYON, 2005).
A 12-year-old female domestic shorthair cat had
a history of weight loss, hyporexia and tooth loss
beginning approximately two months before
presenting to our practice. Physical examination
revealed the presence of ulcers in the oral cavity
(Figure 1), mostly localized on the swollen gums and
tonsils, in addition to pain upon palpation and
mouth opening. The cat also presented dental
calculus on all teeth. Complementary tests were
performed, hyperproteinemia was driven by
hyperglobulinemia, and the FIV/FeLV immune-
Correspondence to:
Aline Silvestrini da Silva
Universidade Federal de Viçosa, Departamento de Medicina
Veterinária
Avenida Peter Henry Rolfs, s/n
CEP 36570- 900, Viçosa, MG, Brazil
e-mail: aline.silvestrini1804@gmail.com
Received: 11/12/2017
Approved: 07/08/2018

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assay was negative for both viruses. Antibiotic
therapy with amoxicillin and potassium clavulanate
(20 mg/kg, twice per day for 21 days) was prescribed
along with prednisolone (1 mg/kg, twice per day for
seven days, followed by a gradual dose reduction) for
initial reduction of swollen tonsils, combined with
periodontal therapy. The treatment temporarily
improved the clinical symptoms. Due to the
recurrent relapses after treatment with antibiotics
and corticosteroid was discontinued, premolar and
molar teeth extraction and oral cavity biopsy
procedures were performed, and the animal was
prescribed ketoprofen (1 mg/kg, once per day for 5
days) for pain management as well as the antibiotic
therapy as previously prescribed.
The histopathological findings revealed the
presence of dense lymphoplasmacytic and
polymorphonuclear inflammatory infiltrate in the
gingival mucosa. Therefore, based on clinical signs
and treatment response, the presumptive diagnosis
of FCGS was confirmed.
Although a follow-up appointment after one
week was recommended, the patient returned two
months after exodontia, presenting hyporexia and
recurrence of the lesions (Figure 2), combined with
dysphagia and sialorrhea. A sample was collected by
sterile gingival swab of the injured areas of oral
cavity. Viral isolation was performed through
inoculation in cell culture, considered the gold
standard in virological diagnosis (Laboratory of
Immunobiological and Animal Virology,
Department of Veterinary - UFV). After
multiplication in cultured cells, the virus was
identified by the cytopathic characteristics of feline
calicivirus present in the sample (Figure 3), which
were compatible with FCV isolation. The patient
returned with complaints of sialorrhea, hyporexia
and dehydration. Upon examination of the oral
cavity, the recurrence of lesions in the gingiva and in
the region of the palatoglossal arch was observed.
Treatment with amoxicillin and clavulanate was
prescribed, and the patient was requested to return
for a follow-up assessment. After four days, the
patient returned with general improvement of the
clinical symptoms and return to normorexia.
Interferon alfa 2A (30 IU/animal, once daily for 7
days) was prescribed with a seven-day interval
without medication until further recommendations.
At submission of this case report, the patient had
been successfully treated with interferon alfa 2A
with an improvement in general condition, and no
subsequent lesions have been observed.
The mucosa of the oral cavity is always exposed
to antigens (VEIR et al., 2002). The immune system
produces antibodies against the antigens, leading to
the activation of the complement system, attracting
phagocytic cells that damage the membranes of
gingival cells (WHITE et al., 1992).
It is common for periodontal disease to occur
concomitant with FCGS lesions. Studies suggest an
association between FCGS and the bacteria involved
in periodontal disease because many affected
animals respond to antibiotic therapy (WHITE et
al., 1992). The patient was initially treated with
antibiotics and corticosteroids, together with the
removal of dental calculi to treat the concomitant
periodontal disease. This resulted in improvement
of clinical signs and symptoms for a short period of
time (NIZA et al., 2004). As the clinical treatment
was not sufficient to keep the animal asymptomatic,
the option was surgical treatment (BELLEI et al.,
2008). Even with extraction of premolar and molar
teeth, the patient returned due to recurrence of the
lesions, an occurrence that is not uncommon. This
fact is reported by Jennings et al. (2015) in a
retrospective study of feline stomatitis, where 67% of
the patients improved with dental extraction, but
most required medical management with
antimicrobial, anti-inflammatory, or analgesic
medications following tooth extraction. Other

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Braz. J. Vet. Res. Anim. Sci., São Paulo, v. 55, n. 3, p. 1-5, e141344, 2018
authors also report that extraction of teeth showed
better results, and clinical cure could reach 50-60%
of the cases. About 20% of the patients presented
persistent caudal discrete stomatitis, but benefited
from the fact that symptoms almost disappeared,
culminating in a better quality of life. Initially,
extraction of premolar and molar teeth is chosen,
but if there is no satisfactory answer, all teeth are
extracted (BELLEI et al., 2008; HOFMANN-
APPOLLO et al., 2010; HUNG et al., 2014).
Figure 1 – Presence of ulcers in the oral cavity of a cat with
Feline chronic gingivostomatitis
Figure 2 – Recurrence of the lesions in cat with Feline
chronic gingivostomatitis
Figure 3 – A) Normal cell culture; B) Cytopathic characteristics of feline calicivirus present in the sample collected from
a cat with Feline chronic gingivostomatitis

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Corticosteroids are widely used in the treatment
of FCGS, but controversy exists related to their use.
In cases with viral involvement, administration of
corticosteroids may contribute to the development
and progression of the disease, and their therapeutic
efficacy decreases over time (NIZA et al., 2004).
Diagnosis is based on patient history, including
progression of the condition, duration of symptoms
and results obtained with previously established
therapy. Physical examination with inspection of the
oral cavity is crucial, but laboratory findings may
also be used, often indicating persistent neutropenia
and hyperglobulinemia (HENNET, 2005; LYON,
2005). Histopathological examination is the gold
standard (LYON, 2005).
Currently, the disease can be treated with
different therapeutic protocols associated or not
with the surgical treatment. Several drugs have
already been used in treatment and responses differ
for each animal. Until now, no treatment has been
shown to be totally effective in promoting disease
cure, only the control of clinical signs (HOFMANN-
APPOLLO et al., 2010).
Considering disease recurrence, refractory
response to treatment and findings of
complementary examinations, total exodontia
combined with immunomodulatory medication and
antibiotic therapy was recommended to prolong the
patient’s life. As interferon has antiviral,
antiproliferative and immunomodulatory effects
that regulate inflammatory processes (NIZA et
al., 2004), a different approach was chosen using
interferon alfa 2A together with periodic control of
plaque accumulation on incisive and canine teeth
with successful results and no subsequent
recurrence of lesions. This is in agreement with a
previously reported case that describes clinical
improvement and reduction of lesions using
immunomodulatory therapy in two cats with FCGS
(LEAL et al., 2013). This treatment has several
advantages, including: (i) decreased number of
surgical procedures, (ii) maintenance of canine teeth
that are important for feline behavior, (iii) avoiding
continuous use of antibiotics in line with worldwide
recommendations for the control of bacterial
resistance and the effect on normal microbiota in the
animal’s gastrointestinal tract and, (iv) promising
results of better life-long symptom control.
The animal was treated several times with
antibiotics and immunosuppressive therapy as it
presented recurrence of the disease even after
extraction of premolar and molar teeth. The owner
made treatment decisions more difficult by failing to
return to the clinic for follow-up appointments on
the dates required to adjust the treatment and
selection of drugs. This case reports successful
immunomodulatory therapy with interferon alfa 2A
after extraction of all premolar and molar teeth,
established based on the inflammatory nature of the
disease and its association with a viral infection.
References
BELLEI, E.; DALLA, F.; MASETTI, L.; PISONI, L.;
JOECHLER, M. Surgical therapy in chronic feline
gingivostomatitis (FCGS). Veterinary Research
Communications, v. 32, p. 231-234, 2008. Supplement 1.
doi: 10.1007/s11259-008-9153-8.
HENNET, P. Relationship between oral calicivirus and
herpesvirus carriage and “palatoglossitis” lesions. In:
ANNUAL VETERINARY DENTAL FORUM & WORLD
VETERINARY DENTAL CONGRESS, 9, 2005, Orlando.
Proceedings… Orlando: Academy of Veterinary Dentistry,
American Veterinary Dental College, American Veterinary
Dental Society, p. 503, 2005.
HOFMANN-APPOLLO, F.; CARVALHO, V. G. G.; GIOSO,
M. A. Complexo gengivite estomatite-faringite dos felinos.
Clínica Veterinária, v. 15, n. 84, p. 44-52, 2010.

| 5
Braz. J. Vet. Res. Anim. Sci., São Paulo, v. 55, n. 3, p. 1-5, e141344, 2018
HUNG, Y. P.; YANG, Y. P.; WANG, H. C.; LIAO, J. W.;
HSU, W. L.; CHANG, C. C.; CHANG, S. G. Bovine
lactoferrin and piroxicam as an adjunct treatment for
lymphocytic plasmacytic gingivitis stomatitis in cats.
Veterinary Journal, v. 202, n. 1, p. 76-82, 2014.
doi: 10.1016/j.tvjl.2014.06.006.
JENNINGS, M. W.; LEWIS, J. R.; SOLTERO-RIVERA, M.
M.; BROWN, D. C.; REITE, A. M. Effect of tooth extraction
on stomatitis in cats: 95 cases (2000-2013). Journal of the
American Veterinary Medical Association, v. 246, n. 6, p.
654-660, 2015. doi: 10.2460/javma.246.6.654.
LEAL, R. O.; GIL, S.; BRITO, M. T. V.; MCGAHIE, D.;
NIZA, M. M. R. E.; TAVARES, L. The use of oral
recombinant feline interferon omega in two cats with type II
diabetes mellitus and concurrent feline chronic
gingivostomatitis syndrome. Irish Veterinary Journal, v. 66,
n. 19, p. 1-4, 2013. doi: 10.1186/2046-0481-66-19.
LYON, K. F. Gingivostomatitis. Veterinary Clinics of North
America: Small Animal Practice, v. 35, n. 4, p. 891-911, 2005.
doi: 10.1016/j.cvsm.2005.02.001.
NIZA, M. M. R. E.; MESTRINHO, L. A.; VILELA, C. L.
Gengivo-estomatite crónica felina – um desafio clínico.
Revista Portuguesa de Ciências Veterinárias, v. 99, n. 551,
p. 127-135, 2004.
VEIR, J. K.; LAPPIN, M. R.; FOLEY, J. E.; GETZY, D. M.
Feline inflammatory polyps: historical, clinical, and PCR
findings for feline calicivirus and feline herpes virus-1 in 28
cases. Journal of Feline Medicine and Surgery, v. 4, n. 4, p.
195-199, 2002. doi: 10.1053/jfms.2002.0172.
WHITE, S. D.; ROSYCHUK, R. A. W.; JANIK, T. A.;
DENEROLLE, P.; SCHULTHEISS, P. Plasma cell stomatitis-
pharyngitis in cats: 40 cases (1973-1991). Journal of the
American Veterinary Medical Association, v. 200, n. 9, p.
1377-1380, 1992.